Cognitive-Behavioral Therapy in the Treatment of Anger: A Meta-Analysis

Cognitive-Behavioral Therapy in the Treatment of
Anger: A Meta-Analysis

Richard Beck1 an d Ephraim Fernandez1‚2
Anger has come to be recognized as a significant social problem worthy of clinical
Attention and systematic research. In the last two decades‚ cognitive-behavioral therapy
(CBT) has emerged as the most common approach to anger management. The overall
Efficacy of this treatment has not been ascertained‚ and therefore‚ it was decided to
conduct a meta-analysis of this literature. Based on 50 studies incorporating 1‚640
Subjects‚ it was found that CBT produced a grand mean weighted effect size of .70‚
Indicating that the average CBT recipient was better off than 76% of untreated subjects
in terms of anger reduction. This effect was statistically significant‚ robust‚ and relatively
Homogeneous across studies. These findings represent a quantitative integration of 20
Years of research into a coherent picture of the efficacy of CBT for anger management.
The results also serve as an impetus for continued research on the treatment of anger.
INTRODUCTION
With violent crime rising among adolescents‚ wide spread familial abuse ‚ continuing
racial discord‚ and recent acts of terrorism‚ attention has turned to anger
as a major problem in human relations (Koop & Lundberg‚ 1992; Novello‚ Shosky‚
& Froehlke‚1992). Yet anger disorders have been neglected in diagnostic classifications
and treatment programs (Eckhardt & Deffenbacher‚ 1995; Kassinove &
Sukhodolsky ‚ 1995) . Increasing references to anger appear in PSYCINFO and other
databases‚ and practitioners are increasingly cognizant of the ramifications of anger
in their clients (Abikoff & Klein‚ 1992; Fernandez & Turk‚ 1993‚ 1995; Koop &
Lundberg‚ 1992) ‚ but little is known about how best to treat anger disorders
In a survey of the literature on anger‚ it was found that the vast majority of
anger treatment outcome studies had utilized a cognitive -behavioral approach. The
present study therefore evaluated the efficacy of cognitive -behavioral therapy (CBT)
in the treatment of anger. Instead of a narrative review‚ a meta-analysis was conducted
to quantitatively integrate the results of individual studies employing CBT
for anger control.
Cognitive-Behavioral Therapy Applied to Anger
Cognitive -behavioral therapy draws upon the rich traditions of behavior modification
and rational-emotive or cognitive therapy (Meichenbaum‚ 1976) ‚ paying attention
to social cognition (Dodge ‚ 1993) as well as individual constructions of
reality (Mahoney‚ 1993) . It may combine a variety of technique s such as relaxation‚
cognitive restructuring‚ problem-solving‚ and stress inoculation‚ but rather than being
a mere form of technical eclectism‚ it is theoretically unified by principles of
learning theory and information processing. This approach has elicited much interest
in the treatment of affective disorders such as anxiety and depression as revealed
in recent meta-analyses by Dobson (1989) and Van Balkom (1994) . The status of
CBT for anger‚ however‚ remains unclear.
Yet the last 20 years has seen an accumulation of research on the efficacy of
cognitive -behavioral therapy in the treatment of anger problems. This research has
focused predominantly on Novaco’s (1975) adaptation of Meichenbaum’s stress inoculation
training (SIT) initially developed for the treatment of anxiety (Meichenbaum‚
1975). Using a coping skills approach‚ stress inoculation interventions are
typically structured into three phase s: cognitive preparation‚ skill acquisition‚ and
application training. During this performance -based intervention‚ the client is exposed
to cognitive reframing‚ relaxation training‚ imagery‚ modeling‚ and role -playing
to enhance ability to cope with problem situations.
In SIT for anger problems‚ clients initially identify situational “triggers” which
precipitate the onset of the anger response . After identifying environmental cues‚
they rehearse self-statements intended to reframe the situation and facilitate healthy
responses (example s of cognitive self-statements include : “Relax‚ don’t take things
so personally” or “I can handle this. It isn’t important enough to blow up over
this”). The second phases of treatment require s the acquisition of relaxation skills.
The cognitive self-statements can then be coupled with relaxation as clients attempt‚
after exposure to the trigger‚ to mentally and physically soothe themselves. Finally‚
in the rehearsal phase ‚ clients are exposed to anger-provoking situations during the
session utilizing imagery or role -plays. They practice the cognitive and relaxation
techniques until the mental and physical response s can be achieved automatically
and on cue. This basic outline of SIT can also be supplemented with alternative
Techniques such as problem-solving‚ conflict management‚ and social skills training
as in the social cognitive model of Lochman and colleague s (Lochman & Lenhart‚
1993).
The purpose of the present study was to evaluate the overall effectiveness of
such cognitive -behavioral treatments for anger by using the methodology of meta analysis.
This entailed computing various summary statistics of the strength of treatment
effect‚ as well as inferential tests of the specific research hypothesis that CBT
statistically significantly reduce s anger. Finally‚ these results were converted into
measures of practical significance . This is particularly informative in the current
climate of managed health care where there is a premium on time-limited interventions
like CBT and growing demands for empirical evidence to support the
choice of treatments. This quantitative synthesis of the literature will also familiarize
readers with the main parameters of research on this topic and gene rate considerations
for further research in this area.
Meta-Analysis
Meta-analysis is a quantitative procedure for evaluating treatment effectiveness
by the calculation of effect sizes (Fernandez & Boyle ‚ 1996; Glass‚ McGraw‚ &
Smith‚ 1981; Rosenthal‚ 1991). The effect size expresses the magnitude of difference
between treated and untreated subjects. Because effect size is expressed in standard
deviation units‚ it enable s comparisons among studies and the computation of summary
statistics such as the grand average effect size‚ an index of overall effectiveness
for the treatment. Despite its advantages over narrative and quasistatistical methods
of review (Fernandez & Turk‚ 1989) ‚ meta-analysis has raised certain concerns which
call for specific solutions (Fernandez & Boyle ‚ 1996) . For example ‚ it has been argued
that effect sizes obtained from studies of varying quality may not be directly
comparable ; consequently‚ it is now customary to weight effects sizes‚ typically according
to objective criteria such as sample size (which determines statistical
power). Concern has also been raised about possible inflation in effect sizes due
to sampling only published studies which are more likely to report significant results
than are non-published studies (the file -drawer problem); this can be counteracted
to some extent by including unpublished studies and also by conducting tests of
robustness that provide a margin of tolerance for null results (Rosenthal‚ 1995) .
To date ‚ the only documented attempt to meta-analyze studies of anger management
was done by Tafrate (1995) . However‚ this review has certain methodological
limitations. First‚ stringent inclusion criteria restricted the number of CBT
studies reviewed to only nine . This small number of studies is unrepre sensitive of
the last 20 years of research on CBT. Tafrate confined his survey to adult sample s
of mostly college students. No doubt‚ students have anger problems too‚ but the
neglect of numerous studies of CBT for oppositional children and adolescents
(populations of primary concern) is problematic. Only three of the studies reviewed
by Tafrate were based on clinical samples‚ thus placing limits on the ecological significance
of results. Unpublished results were ignored‚ and due to the small number
of studies actually reviewed‚ the conclusions reached were probably susceptible to
sampling bias. Finally‚ Tafrate neglected tests of homogeneity‚ tests of significance
or tests of robustness‚ or weighing of effect size s based on any of the design features
of the studies; as emphasized earlier‚ these statistics have now become standard
practice in meta-analytic reviews‚ and they can significantly affect the conclusions
reached.
To improve upon Tafrate’s (1995) initial review‚ the present study expanded
inclusion criteria‚ incorporated unpublished studies‚ and weighted all effect size s.
As de tailed below‚ the scope of the review was broadened to incorporate diverse
samples receiving a combination of cognitive and behavioral technique s. In this way‚
more than five time s the number of CBT studies reviewed by Tafrate were meta analyze
here.

METHOD
Inclusion Criteria
A computer search of PSYCINFO and Dissertation Abstracts International from
1970 to 1995 was conducted. Using keywords such as anger control‚ anger treatment‚
and anger management and cross-references among articles‚ a total of 58 relevant
studies of CBT were identified. Eight of these were single -case or small-sample
studies (n < 4) and hence were exclude d. The final sample consisted of 50 nomothetic
studies incorporating a total of 1640 subjects. All studies provided data
on at least one anger-related dependent variable
In terms of the independent variable ‚ only cognitive -behavioral treatments for
anger were selected. Studies using purely cognitive or behavioral interventions alone
were not included‚ nor were treatments aimed solely at relaxation. Typically‚ the
study included was one in which some form of cognitive reappraisal or restructuring
was combined with some technique of promoting relaxation. The sample s were
predominantly clinical such as prison inmate s‚ abusive parents‚ abusive spouse s‚ juvenile
delinquents‚ adolescents in residential treatment‚ children with aggressive
classroom behavior‚ and mentally handicapped clients‚ but also included college
students with reported anger problems.
Thirty-five studies used self-reported anger as a dependent variable . Effect
sizes for 28 of the 35 studies were calculate d exclusively from self reports of anger.
The remaining seven studies combine d dependent measure s of anger and aggression
into effect size estimate s. Fifteen studies of school children and adolescents
in placement (either residential or detention facility) referred to anger but only
reported behavioral ratings of aggression. Since aggressive behavior has been the
focus in CBT interventions for children and adolescents‚ aggression ratings served
as the dependent variable for the se studies. For younger populations ‚ measure s of
self-reported anger are not always feasible and behavioral ratings of aggression
become a valid alternative ‚ just as self-reports of depression and anxiety in children
may be less accessible than the behaviors corresponding to the se mood disturbances.
Calculation of Effect Sizes
Glass’s d (effect size) was calculated for each study where means and standard
deviations were available for treatment and control groups (Glass et al.‚ 1981). For
studies utilizing single group‚ pre- versus posttest designs‚ and any other studies
not reporting means and standard deviations‚ effect size was estimate d from t- and
F-value s. Where multiple dependent variable s were reported‚ effect sizes were averaged across variable s to yield one effect size per study‚ thus minimizing non independence
in the data.
Adopting procedures recommended by Rosenthal (1991) ‚ each effect size was
weighted by sample size‚ and averaged to yield a grand weighted meand based on
50 studies. Weighting effect size s by sample size is an unbiased and objective procedure
for assigning different weights to studies that vary in statistical power. The
grand weighted mean d was tested for significance (d compared to zero) using a
one -sample t-test‚ and 95% confidence intervals were calculated. A chi square was
also calculated to test for heterogeneity of variance within the set of effect sizes.
The heterogeneity test is the basis for a decision on whether or not to search for
moderator variables; in case of significant heterogeneity‚ it would be necessary to
disaggregate the effect sizes according to the variable s influencing effect size. Finally‚
to address the file -drawer problem a fail-safe N‚ as recommended by Rosenthal
(1991) ‚ was calculated to test for robustness. A robust finding indicate s that
the probability of a Type I error arising from unpublished‚ non significant results‚
is negligible . As strongly recommended by Rosenthal (1995) ‚ a Binomial effect size
display (BESD) was also constructed to provide a more concrete impression of the
relative outcome s in treatment and control groups.
RESULTS
A total of 50 effect size s was obtained for the 50 studies (Table I). Of these‚
40 utilize d control groups while 10 use d single -group‚ repeated-measures designs.
The sample size and design features for each study are also tabulated.
As summarized in Table II‚ the effect size s ranged from ¯0.32 to 1.57‚ SD =
0.43. With only one exception‚ all effect size s were positive in value . The grand
mean unweighted was 0.81. The grand mean weighted effect size was 0.70. This
differed significantly from zero‚ t (49) = 13.28‚ p < .0001. The 95% confidence intervals
for the mean unweighted effect size range d from 0.69 to 0.93. A stem and
leaf plot is shown in Table III to display batches of effect sizes. As can be seen‚
the effect sizes approximate d a normal distribution. Most of the effect sizes were
between 0.5 and 0.99‚ and six effect sizes reached about 1.2‚ thus making this the
mode . A notable outlier was the one negative value in the data set.
Since any effect size is a standard deviation unit (z-score )‚ it can be converted
into a percentile by ascertaining the area under the normal curve that is bounded
between that z-score and the tail end of the curve . Thus‚ the grand weighted mean
effect size of 0.70 corresponds to an are a under the curve of 0.5 + 0.258‚ which
in turn means that the average subject in the CBT treatment condition fared better
than 76% of those not receiving CBT.
To further illustrate the practical importance of these results‚ a binomial effect
size display was added (Table VI). This first entailed conversion of the grand
weighted mean d to r‚ which turned out to be 0.33; as noted in the table ‚ half the
value of r was the n added or subtracted from 0.5‚ revealing that subjects receiving
CBT experienced a 67% treatment success rate whereas control subjects had only
a 33% success rate .

DISCUSSION
Effectiveness of Cognitive-Behavior Therapy in the Treatment of Anger
Re searchers have increasingly focused their attention on CBT as a treatment
for anger disorders. Over the past 20 years‚ many individual studies have
suggested that CBT is an effective ‚ time -limited treatment of anger problems.
Our meta-analysis of 50 nomothetic studies of 1‚640 subjects revealed a
weighted mean effect size of 0.70‚ suggestive of mode rate treatment gains.
Since this is in standard deviation units‚ it can be inferred that the average
subject in the CBT condition was better off than 76% of control subjects. More -
over‚ this effect was significantly different from what would be expected under
chance . The grand effect size was also robust enough to be unaffected by unpublished null results‚ and it was relatively homogeneous across studies. Since
the populations investigated consisted largely of abusive parents or spouse s‚
violent and resistant juvenile offenders‚ inmate s in detention facilities‚ and aggressive school children‚ it is apparent that CBT has general utility in the clinical
management of anger.
These findings imply that the apparent popularity of CBT in the treatment of
anger is justified by its effectiveness in achieving the de sire d treatment goals. The
results are congruent with other meta-analyses documenting the effectiveness of
CBT in the treatment of other affective disturbance s‚ in particular‚ depression
(Dobson‚ 1989) and anxiety (Van Balkom et al.‚ 1994).
At the same time ‚ it may be note d that the grand weighted effect size of 0.70
in this review is smaller than Tafrate’s (1995) reported effect size of 1.00 for CBT
studies (which were labeled as “multi component”); this is probably because the latte
r consisted of only nine published studies‚ none of which were weighted according
to statistical power. On the other hand‚ by sampling unpublished results‚ reviewing
studies with clinical populations ‚ and weighing effect sizes by sample size ‚ the present
study may have produced a slight deflation of effect size ‚ but one that is probably
more reliable .
Future Considerations
This study was an attempt to summarize and document the progress made
over the last two decades of research on CBT for anger treatment research. The
clinical implications of the meta-analysis are encouraging. Clinicians treating clients
with anger control problems can now substantiate their choice of CBT in the treatment
of anger‚ and expect at least mode rate improvements in their clients. Moreover‚ the pre sent findings may serve as a benchmark against which to evaluate other
psychological and pharmacological treatments for anger. Outcome efficacy aside ‚
future research might also address the cost-effectiveness of the se treatments‚ an
issue of growing interest in the currentera of managed care.
New variations of CBT might also be explored. Deffenbacher and colleagues
have already taken a step in this direction with the development of a package called
“cognitive relaxation.” On the other hand‚ Lochman and colleagues have emphasized
training people in encoding of social stimuli and problem-solving within a
social context. With additional studies in these areas‚ it is foreseeable that the most
active ingredients of CBT may be identified and integrate d to produce an even
more effective regimen for managing anger.
Another viable frontier of research might be client variables related to treatment
outcome . These may center around self-efficacy‚ locus of control‚ impulsivity
versus reflectivity‚ and a host of traits predisposing individuals to respond to treatment
in select ways. Clarification of these variables may enable the careful matching
of clients to specific treatment regimens.
Finally‚ ecological validity remains a goal for most treatment outcome research.
In anger management‚ well-controlled laboratory studies have revealed encouraging
treatment effects. But the generalizability of these findings to various clinical and
multicultural populations often needs to be established. Ultimately‚ the ability to
predict and control anger as it occurs spontaneously in different groups of people
within their own naturalistic settings is a challenge worth addressing.

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